2021 Anaesthetics Curriculum
Curriculum review update - May 2020
27 May 2020
Whilst the new curriculum has not yet received approval from the GMC, we are pleased to share the clinical content, which encompasses the domains of High-level Learning Outcomes for stages 1-3 of training and the special interest areas.
Stage 1 – CT1, CT2, CT3
Stage 2 – ST4, ST5
Stage 3 – ST6. ST7
The new Anaesthetics curriculum contains 14 domains that describe the standard that anaesthetists must demonstrate as they progress through training and ultimately attain a CCT. Anaesthetists in training are required to demonstrate achievement of both the generic professional and specialty-specific domains throughout their training period.
Each domain has a High-level Learning Outcome (HLO) that sets the scene for what constitutes an anaesthetist.
Below that is a stage learning outcome that provides a description of attainment to be achieved at the end of that stage in order to progress to the next.
Next follows a set of key capabilities that are mandatory capabilities that must be evidenced by anaesthetists in training to meet the stage learning outcome.
Every HLO at each stage of training includes a selection of illustrations that are examples of evidence and give the range of clinical contexts that anaesthetists in training may use to support their achievement of the key capabilities.
These are intended to provide a prompt to the anaesthetist in training and their trainers as to how the overall outcomes may be achieved. They are not intended to be exhaustive and there are many more examples that would provide equally valid evidence of performance. In addition, excellent anaesthetists in training may produce a broader portfolio of evidence that demonstrates deeper learning. It is not expected that anaesthetists in training provide a set quota of evidence; the aim of assessment is to provide adequate, robust evidence against every key capability to demonstrate acquisition of the HLOs at each stage.
Satisfactory achievement for each stage of training requires demonstration that, for each of the HLOs, the anaesthetist in training’s performance meets or exceeds the minimum requirements as described. This will require educational supervisors to make a global judgement indicating whether satisfactory progress for the defined stage of training has been made.
Name of the curriculum:
We have requested that the new curriculum be known as the ‘2021 Anaesthetics Curriculum’ to reflect the anticipated date of its introduction.
2021 Curriculum Draft Annexes
Frequently asked questions about the new curriculum and transition to it
Following the Junior Doctors Industrial dispute, a review into training supported by patient groups, junior doctors, employers and postgraduate bodies was conducted. Existing training was seen to be rigid, slow to adapt and contained too many tick box exercises. The Shape of Training Review and the GMC’s Excellence by design: standards for postgraduate curricula provided an opportunity to reform postgraduate training to produce a workforce fit for the needs of patients, producing a doctor who is more patient focused, more general and has more flexibility in career structure as recommended by the GMC document Adapting for the future.
These documents have triggered all medical colleges to revise their curricula and incorporate interchangeable and consistent generic professional capabilities at the forefront.
The current CCT curriculum was introduced in 2010 and although there have been detail changes, such as the introduction of Units of Training in Perioperative Medicine, it remains largely unchanged over the last decade. A review of the 2010 curriculum was conducted by Aidan Devlin in 2014 and many of the recommendations have been incorporated into the 2021 curriculum.
The RCoA has used this opportunity to try and improve training for anaesthetists in training. Current data shows that more than 40% of CT2s do not complete core training and move into ST3 after two years. Pressure to pass the FRCA Primary exam and a desire to gain further anaesthetic experience (especially in obstetrics) were cited as particular stressors in the College’s Welfare and Morale Report published in 2017. These issues are addressed in the 2021 curriculum.
No. The 2010 curriculum is an indicative 7 year programme consisting of core training (2 years), intermediate training (2 years), and higher/advanced training (3 years). This totals at 7 years.
The 2021 curriculum is also an indicative 7 years, consisting of Stage 1 (3 years), Stage 2 (2 years), and Stage 3 (2 years).
CT3s will be completing their third year of Stage 1 and will be expected to be working to complete their Stage 1 training. No anaesthetist in training is expected to work beyond what they feel comfortable with or beyond their stage of training. With regards to rotations and rotas, design and implementation will be led by regional schools of anaesthesia and by local departments, respectively. They will aim to fairly balance training needs and local service commitments.
The College aims to ensure no trainee is disadvantaged by the curriculum changes and is pushing to ensure that the payscale will be in-line with the 2016 junior doctor contract, where ST3 and CT3 pay points are identical across the UK.
There will be recruitment (including applications and interview process) into Stage 1 training – the equivalent of the current Core Training recruitment. A requirement for Stage 1 completion is to complete the FRCA Primary. There will be recruitment (including applications and interview process) at Stage 2 training. A requirement during Stage 2 completion is to complete the FRCA Final . There is no recruitment at Stage 3 but entry into Stage 3 requires a successful ARCP and completion of the FRCA Final in Stage 2.
Existing and familiar WBAs will still exist (A-CEX, ALMAT, DOPS, CBD, MSF) and these are aimed at providing constructive formative feedback to anaesthetists-in-training. They should be completed to help show evidence when completing key capabilities in each stage of training. The GMC’s guidance on assessment in postgraduate curricula has shifted from detailed examination of individual elements of competence, towards global assessment of performance based on the opinion of consultant experts. With this in mind, newer assessment methods will be introduced after thorough testing.
This has been a long and complex project which has been ongoing for a number of years. The GMC is currently reviewing the College's curriculum plans and will formally comment on these in early to mid 2020. The new curriculum is set to be rolled out from August 2021. With regards to transition onto the new curriculum, there is a GMC requirement that all anaesthetists in training must be on the new curriculum within 2 years.
From August 2022 there will no longer be any ST3 recruitment and competitive entry to Higher Specialist Training rotations will be at ST4. Core Training programmes in Anaesthesia and ACCS will automatically include an additional year from August 2021. Trainees who complete CT2 in 2021 will be able to apply for Out of Programme (OOP) via their Deaneries if they have already arranged to spend time outside or the training programme or wish to do so and will be able to return to their rotations to complete CT3.
Trainees who have completed CT2 on the 2010 curriculum are expected to be able to access ‘top-up’ posts to gain the additional training required to complete Stage 1 of the new curriculum. We are working with stakeholders including HEE and its equivalents in the devolved nations, Postgraduate Deans, the GMC and the BMA to try to ensure that these posts offer fair terms and conditions (including pay) for those who need to access them.
Trainees who accept an ICM NTN starting in August 2021, and who wish to subsequently apply to dual train with anaesthetics, will need to access ‘top-up’ posts to gain the additional training required to complete Stage 1 of the new curriculum, in order to be eligible to apply for ST4 (Stage 2) posts in anaesthetics. We expect that these posts will take the form of Out Of Programme (OOP) posts after commencement of the ICM programme.
The RCoA will continue to work with stakeholders including the Faculty of Intensive Care Medicine, HEE and its equivalents in the devolved nations, Postgraduate Deans, the GMC and the BMA to try to ensure that these posts offer fair terms and conditions (including pay) for those who need to access them.
We will release further information as soon as agreement has been reached around the exact nature of these ‘top-up’ posts and how they will accessed.
It is also worth noting that dual training programmes can only be developed once all of the corresponding new curricula have received GMC approval.
Previous curriculum review updates
Amendment to the implementation plan:
In view of the significant disruption to training we have amended our plans for transition to the new curriculum. Specifically, in light of the problems with ST3 recruitment this year we will delay transition to an additional year of Core Training for a further 12 months. We will therefore continue to run ST3 recruitment in August 2021 and a final round in February 2022. It is important to note that those who are currently in CT1 or ACCS CT2 will complete a 2 year Core Training programme rather than 3 which had previously been proposed.
We will move those in CT1 and CT2 posts (and ACCS equivalents) to the new curriculum as planned in August 2021 to ensure alignment with the ACCS programme which is also due to commence with its new curriculum at that time.
In August 2022 we will introduce CT3 posts with no further ST3 recruitment from that time and ST4 recruitment commencing in 2023. We expect the timeframe for transition across all grades to be completed by the end of 2023 and will provide more information for transition timelines for each year of training in due course.
Name of the curriculum:
We have requested that the new curriculum be known as the ‘2021 Anaesthetics Curriculum’ to reflect the anticipated date of its introduction.
The College is pleased to provide an update regarding transition from the 2010 anaesthetic curriculum.
The proposed 2020 anaesthetic CCT curriculum is currently under review by the General Medical Council (GMC).
Further details regarding the 2020 curriculum can be found below.
Once GMC approval has been obtained, it is planned that the new curriculum will be implemented from August 2021 with a two-year transition period.
As part of this process, a three-year Core Training programme will be introduced with recruitment to higher training at ST4. The length of the full training programme will remain unchanged at seven years.
Transition will take place at the following times for trainees entering each level of training as below in August 2021:
- new CT1: 2020 curriculum from start of training
- CT2: transition to 2020 curriculum from entry to CT2
- CT3: trainees completing CT2 from August 2021 onwards will continue in an additional third year to complete Core Training on the 2020 curriculum
- ST4: will complete intermediate training then transition to 2020 curriculum at ST5
- ST5: transition to 2020 curriculum on entry to ST5
- ST6/7: remain on 2010 curriculum to CCT (up to two years).
Less than full time trainees and those on out of programme training, maternity or paternity leave will need an individualised plan to ensure they transition to the 2020 curriculum by the deadline of August 2023.
Trainees rotating in February will transition in the same way but six months later.
The College has requested that trainees who have completed CT2 and are not in a training post at the time of the transition will be able to access 12 month posts to complete Stage 1 of the 2020 curriculum.
The College is actively involved in discussions with the GMC, Health Education England, devolved nations and BMA regarding the exact nature of these posts and will release further information as soon as an agreement has been reached. In particular, the College is seeking to ensure that pay and conditions are equivalent to those of anaesthetists in training remaining within the training programme.
Fellows and members may be aware that there is a large project to re-write the anaesthetic curriculum in line with new GMC standards that were published in May 2017.
The proposed new curriculum will include three years core training (four years for ACCS) then four years for higher specialty training. The total indicative duration of the anaesthetic training programme will remain at seven years. There will be three ‘stages’ of training representing three/two/two years (Stage 1 = CT1-CT3 / Stage 2 = ST4-ST5 / Stage 3 = ST6/ST7).
The clinical scope of Stage 1 will be similar to the current core programme, albeit at a more challenging level at CT3 with greater exposure to obstetric anaesthesia after completion of the Initial Assessment of Competence in Obstetric Anaesthesia (IACOA) and paediatrics.
The new curriculum may have implications for future recruitment to higher specialty training, which will start at ST4 ie, Stage 2. Anaesthetists in training will be required to demonstrate acquisition of the learning outcomes necessary for completion of the new three year Stage 1 curriculum critical progression point, before starting Stage 2 specialty training (ST4).
We are aware that this may have implications for those trainees who enter and/or complete core training on the existing 2010 curriculum before August 2021. The College is looking at the solutions available to allow these trainees as smooth a transition as possible from CT2 through to ST4. This involves discussion with other bodies involved in the employment of anaesthetists in training, for example the Conference of Postgraduate Deans and the GMC. Until these discussions are complete we are unable to provide specific details of the transitional arrangements. We hope to be in a more informed position in the autumn. However, we at the College would like to reassure all anaesthetists in training that the curriculum changes have been made for their benefit and we are working to ensure no one will be disadvantaged by this change. Those starting CT1 in August 2019 should anticipate spending three years in core/stage 1 training and should address any concerns in the first instance to their Training Programme Director or Regional Adviser Anaesthesia.
We will provide further information as soon as we are able to do so, and in the meantime if you have any concerns, please feel free to contact your Anaesthetists in Training Representative Group (ATRG) representative who can contact the College Training Department or Trainee representatives on Council who are members of the Curriculum Review Group.
Useful links and documents
- Dr Aidan Devlin's review of the existing 2010 Anaesthetic curriculum, 2014
- General Medical Council – Excellence by design
- General Medical Council – Generic Professional Capabilities Framework
- General Medical Council - Adapting for the Future
- Shape of Training – Report from the UK Shape of Training Steering Group (UKSTSG)
- Health Education England – Enhancing working lives
- Royal College of Paediatrics and Child Health – Progress curriculum
- Joint Royal Colleges of Physicians Training Board – New Internal Medicine curriculum
More about the 2020 curriculum
The current curriculum for a CCT in Anaesthetics was published in 2010. Although a comprehensive review was undertaken in 2015 and changes have been made, the details within the annexes have remained as initially written, and further feedback within the anaesthetic community indicates that there remains room for improvement.
In 2017 the GMC published a new document Excellence by design: standards for postgraduate curricula which requires the curricula for all medical specialties to be revised by 2020, and to comply with certain requirements:
- curricula must introduce Generic Professional Capabilities
- curricula must be structured round a limited number of ‘specialty learning outcomes’- activities that describe the work of an independent clinician in each particular discipline
- each College must demonstrate stakeholder involvement in developing their curriculum
- assessment burden is to be reduced and a ‘tick-box’ approach avoided.
Implementation of the recommendations of The Shape of Training Report also requires all Colleges/Faculties to review their training programmes and curricula content to ensure they fulfill the following key principles of the report, which are that the curriculum:
- takes account of and describes how the [revised curriculum] proposal will better support the needs of patients and service providers
- ensures that the proposed CCT curriculum equips doctors with the generic skills to participate in the acute unselected take and to provide continuity of care thereafter
- where appropriate describes how the proposal would better support the delivery of care in the community
- describes how the proposal will support a more flexible approach to training
- describes the role that credentialing will play in delivering the specialist and sub-specialist components of the curriculum.
This will be a complex project and we must rewrite the anaesthetic curriculum and submit a proposal to the GMC by December 2020 at the latest. We have established a curriculum working group to undertake a wholesale review and to deliver this project, and our aim is to provide a programme of learning and assessment that meet the needs of our specialty, supports the pursuit of excellence and allows learners to flourish.
Generic Professional Capabilities
The GMC has described a series of skills, attributes and behaviours that must be embodied by any autonomous clinical practitioner - Generic Professional Capabilities (GPCs) were published in 2017.
The intention from the outset is that these are common and interchangeable across curricula as far as possible. They were described in response to the finding that curricula across colleges vary significantly, and not all college curricula covered the breadth of the domains of Good Medical Practice.
The GMC also wanted to learn the lessons from high profile reports outlining safety failures and the contribution of shortcomings in the care provided by medical leaders. The GMC has stated that these are to be the building blocks for all curricula and that we must include these as we build content and use them to guide our systems of assessment.
The GPCs framework comprises nine domains:
Although not defined as 'Generic Professional Capabilities', the current 2010 Anaesthetic CCT Curriculum already includes many such ‘common competences’. Annex A describes specific professionalism and common competences that are expected throughout training. They are also embedded in the clinical units of training at all levels, and are expected to be included within the assessments of clinical training. Annex G covers further elements described in the nine GMC domains above.
The implementation of competency based training has made the achievement of skills and knowledge throughout the training programme more explicit, but it is recognised that it has, in some cases, been unwieldy and over burdensome.
To address this, the GMC has suggested that Colleges should frame their curricula around 15 – 20 ‘learning outcomes’. The outcomes have to be described at a ‘high level’ and define the activities that a clinician at the end of training will be able to perform independently.
This is a significant change from the structure of our current 2010 curriculum.
The third element of a GPC/ specialty learning outcome-based model is that clear milestones should exist (critical progression points within the curriculum) outlining progress to be made and with a detailed description of how that is evaluated, alongside a range of assessment tools with primacy for expert faculty judgment.
The GMC’s guidance on assessment in postgraduate curricula has shifted from detailed examination of individual elements of competence, towards global assessment of performance based on the opinion of consultant experts.
It is increasingly recognised that this is a valid method of performance assessment, provided it takes into account multiple assessments by multiple assessors. The overall burden of assessment should be reduced, but the GMC suggests that as a minimum, two or three clinical supervisor reports and an educational supervisor report should be recorded every year, and that a team assessment of behaviour should be performed every 12 months.
In keeping with the desire to simplify, and reduce the burden of assessment, the GMC has also suggested that workplace based assessment moves away from separating out individual elements of performance, and replace them with more global assessment of whole clinical tasks, or 'Entrustable Professional Activities' (EPAs).
EPAs have been described as
‘A clinical activity which a trainee can be trusted to complete with indirect supervision once they have demonstrated the necessary competence to do so’
This approach requires a process whereby ‘entrustment’ is considered. This is the summative decision whereby an expert assessor, or faculty, decides that a learner is ready to work with a proscribed degree of autonomy in the activity in question. At the end of training this level of autonomy is independence. The waypoints to that have been described as milestones or critical progression points.
- In 2014 Dr Aidan Devlin undertook a review of the existing 2010 Anaesthetic curriculum, conducting a survey of fellows and members to learn more about rumoured issues.
- Senior members of the ACRG met with the GMC and the Curriculum Oversight Group (COG) which consists of Deans, representatives from the Shape of Training review and representatives from the Departments of Health, in order to discuss our purpose statement which has received conditional approval from the GMC’s Curriculum Oversight Group (COG).
- Attended GMC led workshops on various issues such as governance, consultation, equality and diversity considerations, and writing learning outcomes.
- Delivered presentations at Regional Advisors Anaesthesia and College Tutors meetings.
- Met with representatives from the Joint Royal Colleges of Physicians Training Board, the Royal College of Emergency Medicine, the Intercollegiate ACCS Committee, Health Education England and COPMeD.
- Learned lessons from colleagues at the JRCPTB and the Royal College of Paediatrics and Child Health who have piloted the new GMC standards and received GMC approval of new curricula.
- Contacted specialist societies and subject matter experts to identify the top ten activities that an anaesthetist on completion of the generalist CCT anaesthetic training programme will be able to perform independently in an area of practice.
- Begun to define the high level outcomes that will form the fundamental structure of the 2020 curriculum.
- Delivered presentations at other meetings such as the Edinburgh Update meeting and the Winter Symposium.